2011_0505CIIECK ONE.
IK RIG ATIO N DOMESTIC FIRELIN E
BACKFT.OW PREVENTION ASSEl��LY TEST AND MALI�TI'ENANC'E REPORT
NAME OF PWS.
PWS I.D. #
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as reduired by TCEQ
regulations and is certiYied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduces Pressure Princin_ le C Pressure Vacuum Breaker
� Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer �. Size �f' �/
Model Number f7 (3 Located At
Serial Number t-/ 1
The above is certified to be true.
Firm Namc
Fitm Address
Gauge #
Date Iast accuracy tested
Cent. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEi�ffiLY
I PRESSURE VACUUM BRF' �1G.'F'R
Double Check Valve Assembly
1st Checl:
Znd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Ti�i o
Leaked D
psid
osid
RP- osid
Leaked c
1 �--'
Did not Open C
Leaked C
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tiwht D
Opened at
Opined at
osid
Repair
Tigltt o
osid
osid
RP sid
The above is certified to be true.
Firm Namc
Fitm Address
Gauge #
Date Iast accuracy tested
Cent. Tester No. Date
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy